The Gift of Care

The Gift, by Lewis Hyde, explores two different human ways of organizing value and relationships. 'Tis the season for today’s ascendant market economies, where transactions prescribe value. Value that is primarily explicit, as in dollars and cents, and with a clear-cut beginning and end apart from returns and warranties. There is an older gift economy, where value is paid forward or comes with tacit obligation. Healthcare lies between these two organizing principles, and it is through this lens that we might understand our patients' dissatisfaction and our “providers '” burnout.

Hyde’s Gift Economy

Hyde begins by distinguishing commodities, things that are owned, priced, exchanged, and consumed, from gifts, whose value and meaning arise through their sharing. One need look no further than the gift your child made at age 6 or 7 to recognize the distinction. 

Commodities emphasize separation (“this is mine, that is yours”), while gifts emphasize connection (“this moves between us”), generating a different kind of obligation. Gift giving expresses recognition of shared care and interdependence, whereas commodity exchange aims to settle accounts. Once equivalence is measured—“I gave you X, you owe me Y”—the gift collapses into barter. True gifts leave recipients not indebted, but grateful, sustaining open-ended relationships rather than closing transactions.

In a gift economy, value comes from circulation; possessing or hoarding a gift strips it of its meaning. The obligation is not repayment, but passage, keeping the gift moving to others. This logic has surprising relevance for medicine.

The Gift of Care

Physicians and nurses are stewards of a gift that comes from their training in diagnostics and therapeutics. These skills have little proprietary value of their own; their value lies in sharing them with their patients. We can clearly see giving in moments of bedside care, but it can also be found in less visible parts of health care, such as teaching rounds, end-of-shift handoffs, and the mentoring that all teams share to some degree. 

As Hyde argues in relation to gift economies, the gift of care need not be hoarded; its power lies in circulation. It exists only in a relationship, here between clinician and patient. Research showing that clinical judgment and technical skill improve with experience reinforces this idea: care is not depleted by use, but strengthened through practice.

Nurses are most frequently the sharp point of care in the hospital, while physicians assume that role, although to a lesser degree, with the advent of physician “extenders, in outpatient settings. Across roles, medicine is translated into human presence through listening. This gift of presence, undistracted by screens, attentive, and responsive, is essential to healing. Without it, care risks becoming mechanical and alienating. 

“Attending,” as a noun, names the primary treating physician; as a verb, it captures the heart of the patient-clinician relationship. It is fragile and easily lost early in our encounters, especially when patients seek, or physicians provide, care from “any willing provider.” The rising tide of patient discontent is testimony to the healthcare marketplace. Healthcare systems commodify care into billing codes, relative value units (RVUs), and time slots. The rising tide of patient discontent reflects that quantified marketplace, where the most significant complaints are that they are not seen or heard – they are not attended to. Healing depends on gift-like acts of attending – staying a few extra minutes, noticing fear, translating complexity into understanding.

Burnout

Systems that treat care purely as commodity labor exhaust the gift and the giver. Burnout is too much extraction, too little replenishment. Gifts of care are not tit for tats that can be recorded in a ledger. Patients do not “repay” care in kind, nor do clinicians act solely for financial compensation – many are still “called” to their work. It explains why clinicians are emotionally exhausted when systems treat the hallmarks of the gift of care, time, attention, or compassion as inefficiencies.

Medicine cannot function without the marketplace. It provides scale and, in some instances, access and accountability. However, the baggage of bean counters, excessive documentation and checklists, EHRs that require endless scrolling and attention, throughput pressure, and metric-driven care interrupts the care experience. Physicians and nurses operate at this fault line. Their work is meaningful precisely because it cannot be fully monetized without losing its animating force.

In the last few months, we have shut down the government, and then argued over appropriations, offsets, premiums, payment rates, and who pays how much, as though healthcare were primarily an accounting problem. The gift of care—attention freely given, presence unmeasured, skill shared in trust—cannot survive when treated as a commodity to be extracted as efficiently as possible. Patients feel this loss as not being seen or heard; clinicians experience the exhaustion that comes when a gift is endlessly taken but never allowed to circulate. Markets can support medicine, but they cannot animate it. When policy and management attend only to money, they crowd out gratitude, connection, and meaning, leaving behind a technically functional system that heals less well. In neglecting the gift of care, we diminish both the care we offer and the people who provide it, and no amount of financing can compensate for what is lost.